Menopausal bone loss in long-term users of depot medroxyprogesterone acetate contraception

U.S. Medical Eligibility Criteria for Contraceptive Use, 2024

The 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by persons who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. MEC (CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR 2016:65[No. RR-3]:1-103). Notable updates include 1) the addition of recommendations for persons with chronic kidney disease; 2) revisions to the recommendations for persons with certain characteristics or medical conditions (i.e., breastfeeding, postpartum, postabortion, obesity, surgery, deep venous thrombosis or pulmonary embolism with or without anticoagulant therapy, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, high risk for HIV infection, cirrhosis, liver tumor, sickle cell disease, solid organ transplantation, and drug interactions with antiretrovirals used for prevention or treatment of HIV infection); and 3) inclusion of new contraceptive methods, including new doses or formulations of combined oral contraceptives, contraceptive patches, vaginal rings, progestin-only pills, levonorgestrel intrauterine devices, and vaginal pH modulator. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.

Adverse bone effects of medications used to treat non-skeletal disorders

There is a growing list of medications used to treat non-skeletal disorders that cause bone loss and/or increase fracture risk. This review discusses glucocorticoids, drugs that reduce sex steroids, antidiabetic agents, acid-reducing drugs, selective serotonin reuptake inhibitors, and heparin. A number of drugs are known to cause bone loss, increase fracture risk, or both. These drugs should be used in the lowest dose necessary to achieve the desired benefit and for the shortest time necessary, but in many cases, long-term treatment is required. Effective countermeasures are available for some.

Prevalence of Low Bone Mass and Osteoporosis in Long-Term Users of the Injectable Contraceptive Depot Medroxyprogesterone Acetate

BACKGROUND

Bone mineral density (BMD) loss among depot medroxyprogesterone acetate (DMPA) users is a controversial issue. Aspects under debate include whether the number of years of use has any effect on continuous BMD loss, whether this loss will stabilise over the years of use or if it will progress to low bone mass, osteoporosis and an increased fracture risk. The aim of this study was to compare the difference in osteoporosis and low bone mass between DMPA and copper intrauterine device (Cu-IUD) users.

METHODS

This was a cross-sectional study that evaluated BMD at the lumbar spine and femoral neck in 47 long-term DMPA users and 41 Cu-IUD users as control group. BMD was measured by dual-energy X-ray absorptiometry. The participants were 27 to 57 years of age, had used either DMPA or a Cu-IUD uninterruptedly for at least ten years, had initiated use of the method prior to 40 years of age and had follicle stimulating hormone values <40 mIU/mL.

RESULTS

Findings showed that 68.1% and 36.6% of the DMPA and Cu-IUD users, respectively, had low bone mass and 29.8% and 2.4% of DMPA and Cu-IUD users, respectively, had osteoporosis. BMD decreased as the number of years of DMPA use increased.

CONCLUSION

Long-term DMPA use was associated with low bone mass and osteoporosis in women who had used the method for 10 years or more. DMPA users with longer time of use showed a greater bone mass loss.

Adverse skeletal effects of drugs - beyond Glucocorticoids

Osteoporotic fractures are an important public health problem with significant individual and societal costs. In addition to the major risk factors for osteoporotic fracture, low bone mineral density (BMD), age, low body weight and history of fracture or falls, some drugs are now considered to be important secondary risk factor for bone loss and fracture, particularly amongst predisposed individuals. Currently available data are often generated from small observational clinical studies, making risk assessment and development of management guidelines difficult. In many cases, the exposed population has a low baseline risk for fracture and additional assessment and treatment may not be necessary. In this review, we focus on drugs other than glucocorticoids identified as potentially causing adverse skeletal effects, summarizing the existing evidence from preclinical and clinical studies, and suggest recommendations for patient management.

Contraception for women over 40

Nurse practitioners can help women 40 and older make contraceptive choices that are effective, safe, and appropriate. The noncontraceptive benefits of some methods may be particularly relevant to women in this age group. Providing women with information about continuing fertility as they approach menopause and when it is safe to discontinue contraception may help to reduce unplanned pregnancies.

Update on hormonal contraception and bone density

Combination hormonal contraception and progestin-only contraception (including depot medroxyprogesterone acetate [DMPA]) are effective and convenient forms of reversible contraception that millions of women use worldwide. In recent years, observations of reduced bone mineral density in current users of these methods have led to concerns that this hormone-induced bone loss might translate into long-term increased fracture risk. Special focus has been placed on adolescent users who have not yet attained their peak bone mass as well as perimenopausal users. In 2004, the FDA added a black box warning to DMPA package labeling warning of the risk of significant bone loss and cautioning against long-term use (> 2 years). This article reviews evidence on the use of hormonal contraception and its effect on bone density in adolescent, premenopausal, and perimenopausal populations. Recommendations from reproductive healthcare organizations are reviewed and clinical recommendations are provided.

Endometriosis: current therapies and new pharmacological developments

Endometriosis is a chronic inflammatory condition that is responsive to management with steroids. The establishment of a steady hormonal environment and inhibition of ovulation can temporarily suppress ectopic implants and reduce inflammation as well as associated pain symptoms. In terms of pharmacological management, the currently available agents are not curative, and treatment often needs to be continued for years or until pregnancy is desired. Similar efficacy has been observed from the various therapies that have been investigated for endometriosis. Accordingly, combined oral contraceptives and progestins, based on their favourable safety profile, tolerability and cost, should be considered as first-line options, as an alternative to surgery and for post-operative adjuvant use. In situations where progestins and oral contraceptives prove ineffective, are poorly tolerated or are contraindicated, gonadotrophin-releasing hormone analogues, danazol or gestrinone may be used. Future therapeutic options for managing endometriosis must compare favourably against existing agents before they can be considered for inclusion into current practice. Finally, as reproductive prognosis is not ameliorated by medical treatment, it is not indicated for women seeking conception.

Effect of depot medroxyprogesterone acetate on bone density in a Scottish industrial city

OBJECTIVE

To determine if long-term users of depot medroxyprogesterone acetate injectable contraception (DMPA) were more likely than their peers to have low bone density.

DESIGN

Cross-sectional observational study.

SETTING

The Domiciliary Family Planning Service, Glasgow, Scotland.

SUBJECTS

Clients of the Domiciliary Service who had used DMPA for contraception for longer than 5 years (mean 12 years) were invited to participate and select their own control, a friend or relative who had never used this method of contraception.

MAIN OUTCOME MEASURES

Bone density measured at the hip and lumbar spine by dual X-ray absorptiometry (DXA).

RESULTS

DMPA users had a significantly lower bone density than controls, 12-13% less at both hip and lumbar spine. This difference remained even when controlling for parity, smoking, family history of kyphosis or hip fracture, and body mass index.

CONCLUSIONS

DMPA significantly decreases bone density in a group of long-term users with significant social deprivation. The long-term significance of this remains uncertain.

Subcutaneous DMPA vs. intramuscular DMPA: a 2-year randomized study of contraceptive efficacy and bone mineral density

BACKGROUND

A formulation of depot medroxyprogesterone acetate (DMPA) has been developed that allows subcutaneous injection (104 mg/0.65 mL; DMPA-SC) and achieves highly effective contraception with a similar tolerability profile to intramuscular DMPA (150 mg/mL; DMPA-IM).

STUDY DESIGN

This randomized, evaluator-blinded study was designed to compare efficacy, safety, and user satisfaction in women receiving DMPA-SC (n=266) or DMPA-IM (n=268) for 2 years with an option to continue for a third year. The primary objectives were to evaluate bone mineral density (BMD) changes and contraceptive efficacy after 2 years.

RESULTS

A total of 225 women completed the first 2 years of this study (DMPA-SC, n=116; DMPA-IM, n=109). After 2 years of DMPA use, BMD loss was marginally smaller in the DMPA-SC group than in the DMPA-IM group at both the total hip (-3.3% and -3.6%, respectively) and lumbar spine (-4.3% and -5.0%, respectively). In those women who received DMPA during the third year, there were no statistically significant differences in BMD loss between DMPA-SC and DMPA-IM groups at the end of Year 3. Recovery of BMD was observed in the small subpopulation of women who had discontinued DMPA-SC or DMPA-IM after the second year. The 2-year treatment-failure cumulative pregnancy rate was 0% in the DMPA-SC group and 0.8% (95% confidence interval, 0.00-2.37%) in the DMPA-IM group (life-table method). Adverse events were similar in the two groups except that injection site reactions were more common in the DMPA-SC group.

CONCLUSION

DMPA-SC is an effective and well-tolerated contraceptive option, providing comparable efficacy and BMD safety to DMPA-IM.

The use of depot-medroxyprogesterone acetate in contraception and its potential impact on skeletal health

BACKGROUND

In the fall of 2007, the controversy about the contraceptive use of depot-medroxyprogesterone acetate (DMPA) and its potential impact on skeletal health reached the media in the province of Quebec, Canada, thereby becoming a matter of concern for the lay public and physicians. In order to discuss this subject openly, the National Institute of Public Health of Quebec (INSPQ) organized a scientific meeting on February 15, 2008, with targeted physicians delegated by their medical associations in the fields of general practice, obstetrics and gynaecology, rheumatology, orthopaedic surgery, physiatry and endocrinology.

STUDY DESIGN

Participants reviewed the scientific literature using the study classification method according to the level of evidence, reviewed published guidelines of medical societies and organizations on the subject and reached a consensus position. This manuscript presents a review of the literature and describes the consensus position of the targeted medical associations.

RESULTS

The consensus position adopted by all the targeted medical associations determined that DMPA was a cost-effective contraceptive option that must be considered in the light of the clinical situation and preference of each woman. Candidates for injectable contraception should be informed that the use of DMPA is associated with a slight decrease in bone mineral density (BMD), which is largely, if not completely, reversible. There should not be an absolute limit to the length of time that the DMPA contraceptive is used, regardless of the woman's age. Monitoring BMD is not recommended among users of DMPA for contraceptive purposes. Finally, the consensus statement declared that, although supplements of calcium and vitamin D are beneficial for skeletal health for women in general, such supplementation should not be recommended solely based on a woman's use of DMPA.

CONCLUSION

Given the scientific evidences, DMPA use remains a valid contraceptive option for women. Its potential impact on BMD must be balanced against the significant individual, familial and social consequences of unintended pregnancy.

Contraception in women with medical problems

Women with medical disease have a higher incidence of maternal mortality compared with healthy women, with cardiac disease now being the most common cause of maternal death in the UK. A handful of medical conditions exist where pregnancy is not recommended due to mortality rates approaching 50%. It is imperative that such women have the most reliable methods of contraception available. Contraceptive agents may themselves affect medical disease, or may interact with medications used by such women. There may be a range of contraceptive agents suitable for each medical condition. The contraceptive selected should be tailored to suit the individual. The following points should be considered when deciding on the most appropriate contraceptive agent: efficacy, thrombotic risk (oestrogen containing contraceptives), arterial risks (oestrogen containing contraceptives), infective risk (e.g. insertion of intrauterine device [IUD]), vagal stimulation (e.g. insertion of IUD, ESSURE(®)), bleeding risks with patients on anticoagulants, interaction with concomitant drugs, effects of anaesthesia and ease of use. This review aims to cover the different contraceptive agents available and the best ones to use for certain medical illnesses.

Hormonal contraception and HIV-positive women: metabolic concerns and management strategies

As HIV-positive women live longer lives, and as testing for HIV becomes more routine, clinicians can expect to see more HIV-positive women in their practices. The need to be aware of management issues particular to this population becomes increasingly important. Metabolic dysregulation is a common, long-term complication associated with HIV and is one of the most difficult to manage. Hormonal contraception also is associated with metabolic dysregulation. As more HIV-positive women choose long-term, reversible contraception, the potential for concomitant and additive side effects, and the need for careful, proactive management strategies to avoid these complications, will become more important. This article reviews research detailing the metabolic dysfunction associated with hormonal contraception and with HIV-seropositivity. It highlights reasons for concern regarding the potential, although as yet theoretical, increased risk for metabolic dysfunction when hormonal contraception is used in the presence of HIV. Suggestions for management strategies for women living with HIV who choose to use hormonal contraception are presented. These strategies should be viewed as suggestions for management until substantitive research becomes available.

Forearm bone mineral density in postmenopausal former users of depot medroxyprogesterone acetate

BACKGROUND

The aim of the study was to compare the bone mineral density (BMD) of postmenopausal women who had used depot-medroxyprogesterone acetate (DMPA) or a copper intrauterine device (IUD) as a comparison group until menopause.

STUDY DESIGN

BMD was measured using dual-energy X-ray absorptiometry at the nondominant forearm for up to 3 years following menopause in 135 women aged 43-58 years: 36 former DMPA users and 99 former IUD users.

RESULTS

Mean duration of use was (mean+/-SEM) 9.4+/-3.8 and 14.7+/-6.2 years for the DMPA and IUD groups, respectively. One year after menopause, mean distal radius BMD was 0.435 and 0.449 in DMPA and IUD users, respectively, and 0.426 and 0.447 at 2-3 years following menopause. Ultra-distal BMD was 0.369 and 0.384 in DMPA and IUD users, respectively, at 1 year, and 0.340 and 0.383 at 2-3 years.

CONCLUSIONS

At 1 and 2-3 years following menopause, no significant differences were observed in the BMD of postmenopausal women aged 43-58 years, who had used DMPA or an IUD until menopause.

Bone density recovery after depot medroxyprogesterone acetate injectable contraception use

BACKGROUND

While depot medroxyprogesterone acetate (DMPA) is a highly effective contraceptive used by millions of women, its use is associated with bone mineral density (BMD) loss, raising concerns about long-term risk of osteoporosis and/or fractures.

STUDY DESIGN

We conducted a systematic review of studies published in PubMed from 1996 to 2006, evaluating changes in BMD after discontinuation of DMPA. Ten primary clinical or observational studies were identified addressing this issue.

RESULTS

BMD consistently returned toward or to baseline values following DMPA discontinuation in women of all ages. This recovery in BMD was seen as early as 24 weeks after stopping therapy and persisted for as long as women were followed up; BMD in past DMPA users was similar to that in nonusers.

CONCLUSIONS

Bone loss occurring with DMPA use is reversible and is not likely to be an important risk factor for low bone density and fractures in older women, although data on fracture risk in DMPA users are lacking.

Contraceptive options during perimenopause

During the transition years leading to menopause, the possibility of conception persists, although at a lower rate. Contraceptive choices available to perimenopausal women are as varied as those for their younger counterparts, albeit with some limitations related predominantly to coexisting medical conditions rather than the advancing age itself. In this review, different contraceptive choices pertaining to this age group will be discussed, with a focus on evidence-based data.

Effects of the long-term use of depot medroxyprogesterone acetate as hormonal contraceptive on bone mineral density and biochemical markers of bone remodeling

PURPOSE AND METHOD

Our objective is to evaluate the effects of the long-term use of depot medroxyprogesterone acetate (DMPA) as a method of contraception on bone mineral density (BMD) and bone remodeling. Forty women (21-44 years old) who used DMPA for contraception for <1, 1-2 and >5 years, in addition to 20 age-matched healthy women (nonusers), participated in this study. Lumbar spine BMD (LS-BMD) was measured by dual-energy X-ray absorptionmetry. Serum osteocalcin (OC), a bone formation marker, was measured by enzyme amplification sorbent immunoassay. Urinary deoxypyridinoline (DPD), a bone resorption marker, was determined by enzyme immunoassay.

RESULTS

Serum OC and urinary DPD levels in women who used DMPA for <1, 1-2 and >5 years were significantly increased compared to the corresponding levels in nonusers. The increase of both biomarkers was more pronounced with longer duration of use. LS-BMD was significantly decreased in women on long-term DMPA use compared to LS-BMD in nonusers. The mean percentage decrease of LS-BMD in women who used DMPA for 1-2 and >5 years was 9% and 11.8%, respectively. LS-BMD was negatively correlated with serum OC and urinary DPD in women who used DMPA. On the other hand, LS-BMD and bone turnover were not significantly different between women who used DMPA for <1 year and nonusers.

CONCLUSION

Long-term use of DMPA (>2 years) had a significant adverse effect on BMD and induced increased bone turnover, as evidenced by a significant increase in biochemical indices of bone formation and resorption. The measurement of LS-BMD and of biomarkers of bone turnover may be recommended in women aged above 40 years and who used DMPA for a long duration (2-5 years).

Progestogen-only contraception and bone mineral density: a systematic review

Questions have been raised about the effects of progestogen-only contraceptive use on bone health, particularly among young women who have not yet reached peak bone mass and perimenopausal women who may be starting to lose bone mass. We conducted a systematic review that evaluated the association between progestogen-only contraceptive use and fracture risk or bone mineral density (BMD). We identified 39 articles from MEDLINE and EMBASE, published through July 2005. One study reported that depot medroxyprogesterone acetate (DMPA) users were more likely to experience stress fractures than nonusers; this association was not statistically significant after controlling for baseline bone density. In cross-sectional studies, the mean BMD in DMPA users was usually below that of nonusers, but within 1 SD. In longitudinal studies, BMD generally decreased more over time among DMPA users than among nonusers, but women gained BMD upon discontinuation of DMPA. Limited evidence suggested that use of progestogen-only contraceptives other than DMPA did not affect BMD.

Bone mineral density in women aged 40–49 years using depot-medroxyprogesterone acetate, norethisterone enanthate or combined oral contraceptives for contraception

Most studies show that depot-medroxyprogesterone acetate (DMPA) has a negative effect on bone mass. There are conflicting reports with respect to recovery of bone mass with long-term use of DMPA. No information is available on the effect of norethisterone enanthate (NET-EN) on bone mass, and combined oral contraceptives (COCs) have not been found to be associated with loss of bone mass. The aim of this study was to investigate bone mineral density (BMD) in older women (40-49 years) in relation to use of DMPA, NET-EN and COCs for at least 12 months preceding recruitment into the study. One-hundred twenty-seven users of DMPA, 102 NET-EN users and 106 COC users were compared to 161 nonuser controls. Bone mineral density was measured at the distal radius and midshaft of the ulna using dual X-ray absorptiometry. There was no significant difference in BMD between the four contraceptive user groups (p=.26) with and without adjustment for age. Although a small decrease in BMD was noted in the age range of 40-49 years, this was not statistically significant (p=.7). The BMD was found to be significantly associated with body mass index (BMI) (p<or=.0001) at both measurement sites, with an increase of one unit of BMI translating to an increase of 0.0044 g/cm2 in radius BMD. Follicle-stimulating hormone (FSH) level >or=25.8 mIU/mL was associated with a decrease of 0.017 g/cm2 in radius BMD relative to women with FSH <25.8 mIU/mL. Significant interaction between FSH and BMI in their effect on BMD was observed (p=.006). This study found no evidence that long-term use of DMPA, NET-EN and COCs affects BMD in this population.

Effects of hormonal contraception on bone mineral density after 24 months of use

OBJECTIVE

To measure the effect of 24 months of depot medroxyprogesterone acetate use on bone mineral density compared with oral contraception (pills) and nonhormonal contraception.

METHODS

Women aged 18-33 years self-selected oral contraception, depot medroxyprogesterone acetate, or nonhormonal contraception (controls). Those selecting pills were randomized to formulations containing either 35 microg ethinyl estradiol and norethindrone or 30 microg ethinyl estradiol and desogestrel. Controls were frequency matched on age and race/ethnicity to hormonal contraception users. Dual-energy X-ray absorptiometry of the lumbar spine (L1-L4) was performed at baseline, 12 months, and 24 months. Percent change in bone mineral density was analyzed by using analysis of covariance, adjusting for age, race/ethnicity, weight-bearing exercise, calcium intake, smoking status, and body mass index.

RESULTS

Of the 191 women making up the final sample, 86 used pills, 47 used depot medroxyprogesterone acetate, and 58 used nonhormonal contraception. Women using depot medroxyprogesterone acetate for 24 months experienced, on average, a 5.7% loss in bone mineral density, with a 3.2% loss occurring between months 12 and 24. On average, users of desogestrel pills experienced a 2.6% loss in bone mineral density after 24 months. Bonferroni-adjusted pairwise comparisons demonstrated that bone mineral density changes from baseline to 24 months among depot medroxyprogesterone acetate users differed significantly from changes experienced by either of the pill groups or the control group. Changes in bone mineral density among users of either pill did not significantly differ from each other or from controls.

CONCLUSION

Loss of bone mineral density associated with depot medroxyprogesterone acetate use appears to be linear during the first 2 years of use. Shifts in bone mineral density among pill users were not significant when compared with controls.

Nondaily Hormonal Contraception: Considerations in Contraceptive Choice and Patient Counseling

PURPOSE

To review currently available choices for non-daily hormonal contraception, considering efficacy, safety, patient counseling issues, and appropriate patient selection.

DATA SOURCES

Worldwide medical literature and the individual products' prescribing information.

CONCLUSIONS

Patients and clinicians have many nondaily hormonal contraceptive options available--from Depo-Provera quarterly injection, which has been available in the United States for over 10 years, to several new entries (Mirena 5-year intrauterine system, Lunelle monthly injection, NuvaRing monthly intravaginal ring, and Ortho Evra weekly transdermal patch). All these options offer high efficacy and enhanced convenience for many patients over daily oral contraceptives (OCs). Barriers to use of these agents may include patients' lack of information as well as fear or misconceptions regarding the hormones and methods. All of these can be addressed with adequate patient counseling and open dialogue. The clinician and patient need to be well-informed regarding these options so that they can work together and identify the best contraceptive fit for the patient---with the ultimate goal being to increase patient satisfaction and adherence and, thus, avoid unintended pregnancy.

IMPLICATIONS FOR PRACTICE

Despite the efficacy of OCs, missed pills are quite common and contribute to unintended pregnancy. Many women in all population categories would benefit from the convenience and reliability of nondaily hormonal contraceptives. The highest efficacy rates with typical use are associated with agents that require minimal user participation (i.e., Depo-Provera, Mirena). Compared to daily regimens, all nondaily options offer increased convenience and may contribute to improved patient adherence. However, barriers to use may exist. Patient fears regarding use of hormones can be minimized by discussing the long-term safety of hormonal contraceptives. (The data are predominantly derived from Depo-Provera and OCs because these agents have been available in the United States and in the rest of the world for much longer than the newer nondaily options.) Patient counseling and appropriate expectations regarding changes in menstrual pattern have been demonstrated to further enhance patient adherence to therapy. Finally, patient lifestyle preferences must be considered. The finding that many women are comfortable with or even prefer amenorrhea, which is associated with options such as Depo-Provera, highlights how important it is for clinicians to avoid making assumptions about a patient's contraceptive preferences. Rather, clinicians and patients should exchange information through an open dialogue. For the majority of patients, nondaily hormonal contraceptives should be considered and offered as first-line options.

Overview on the effects of progestins on bone

In view of the fact that fractures are the clinically relevant events, risk factors for fractures are discussed first. Bone mineral density (BMD) appears to be a much less important risk factor for the most severe hip fractures than the risk of falling. No results of experimental studies on hormones and fractures at advanced age are available. An overview of the effects of progestins on bone is given. Effects of progestins on bone have been studied by in vitro experiments using cell lines and by more relevant clinical observations. Prospective studies have been conducted following the use of progestins contained in oral contraceptives, alone or in combination with oestrogens; long-term contraception by injection of depot preparations; so-called "add-back" hormonal therapy attempting to reverse the adverse effects of gonadotropin releasing hormone agonists on bone and after different regimens of hormone replacement therapy (HRT) in postmenopausal women. From the data there are no indications that the various progestins, used in clinical practice, have either a bone-protective or an oestrogen antagonistic activity. Progestins do not add or subtract much of the protective action of oestrogens on the bones.

Disorders associated with acute rapid and severe bone loss

We describe a constellation of bone diseases characterized by the common feature of acute, rapid, and severe bone loss accompanied by dramatic fracture rates. These disorders are poorly recognized, resulting mainly from systemic diseases, frailty, immobilization, and immunosuppressive drugs, such as glucocorticoids and the calcineurin inhibitors. The opportunity to prevent or treat fractures is commonly missed because they are often not detected. Ideally, patients need to be identified early and preventative therapy initiated promptly to avoid the rapid bone loss and fractures. The most effective therapy at present seems to be the bisphosphonates, particularly when bone resorption is predominant. However, more severe forms of bone loss that result from an osteoblastic defect and reduced bone formation may benefit potentially more from newer anabolic agents, such as recombinant human parathyroid hormone (rhPTH).

Depot-medroxyprogesterone acetate injection (Depo-Provera): a highly effective contraceptive option with proven long-term safety

Depot-medroxyprogesterone acetate (Depo-Provera(R)) is a highly effective, nondaily hormonal contraceptive option that has been available in the United States for a decade, and worldwide for 40 years. Benefits and risks of hormonal therapy are often under scrutiny; however, long-term clinical experience has established the safety of this long-acting contraceptive. This article reviews the contraceptive efficacy, potential noncontraceptive health benefits and long-term safety of with regard to risk of cardiovascular events, breast and gynecologic malignancy and osteopenia. Comparisons with other hormonal contraceptives are made as clinically appropriate. Common patient management issues, including effects on menstrual cycle, body weight and mood, are also addressed. Finally, this review provides recommendations for appropriate patient selection.

A randomized controlled trial of estrogen replacement therapy in long-term users of depot medroxyprogesterone acetate

Long-term use of the injectable contraceptive depot medroxyprogesterone acetate (DMPA, Depo-Provera) is associated with a reduction in bone mineral density (BMD), particularly in the lumbar spine. The cause of DMPA-associated bone loss is not known, but the relative estrogen deficiency induced by DMPA use could be responsible. We have undertaken a randomized, double-blind controlled trial of oral estrogen replacement therapy in 38 premenopausal women (mean age 37) with a minimum 2 yr DMPA use who had a below average baseline lumbar spine BMD (T score < or = 0). Nineteen women were allocated to receive conjugated estrogens (0.625 mg/d orally) and 19 to receive a matching placebo. All continued with regular DMPA injections throughout the study. Areal bone density was measured by dual energy x-ray absorptiometry at the lumbar spine, femoral neck, and total body sites every 6 months for 2 yr; the main outcome measure being the change in areal BMD at the lumbar spine. At baseline, the two groups were well matched for demographic, anthropometric, and biochemical variables, and for BMD. Twenty-seven subjects completed at least 18 months in the study, and 26 the full 2 yr, with similar numbers dropping out from each group (mainly for personal reasons). In the estrogen-treated group, mean lumbar spine BMD increased 1%, whereas in the placebo group it fell 2.6%, over 2 yr. The between group differences were 2.0% at 12 months (P = 0.058), 3.2% at 18 months (P < 0.01), and 3.5% at 24 months (P < 0.002). Differences of lesser statistical magnitude were seen at the femoral neck (between group differences at 2 yr: 2.7%, P = 0.24), Ward's triangle (5.0%, P = 0.055), greater trochanter (3.6%, P = 0.056), total body (1.3%, P = 0.046), legs (1.3%, P = 0.065), and trunk (2.0%, P = 0.029). There were no major adverse events. These data support the view that the likely cause of DMPA-associated bone loss is estrogen deficiency and demonstrate that it can be arrested by estrogen replacement therapy.